The White Noise Podcast

In this months episode we will be discussing all things Inspire with Dr. Paul Hoff, an ENT at Michigan Medicine.  What is Hypoglossal Nerve Stimulation? Who can get it? Does it Even work? Listen as we answer all your burning questions.  Show Notes 3:00 get to know you questions 9:20 Favorite Book Best Advice 10:00 The Inspire Case 11:00 What type of sleep study? 18:20 AHI Cutofffs: 18:55 Goals of Care? 21:50 What is considered effective therapy? 24:30 Star Trial link: Upper-Airway Stimulation for Obstructive Sleep Apnea | NEJM Adhere Registry Link: Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy - Thaler - 2020 - The Laryngoscope - Wiley Online Library Define CPAP failure? 26:00 Nasal obstruction causing CPAP failure 28:00 Floppy Epiglottis causing Aerophagia? 28:30 Surgery for Aerophagia 29:30 Risks and medical contraindications 33:00 MRI compatibility? 33:30 Surgery description/length 34:30 ICD compatibility? 35:00 Avg Voltage ranges? 37:00 Removing devices 39:00 Recovery time 39:40 Incision size 40:45 Back to the case, parameters for referral 43:00 Drug Induced Sleep Endoscopy (DISE) 43:45 What percentage of patients fail DISE? 47:00 Management after Inspire placement 48:15 Inspire sync: 49:15 Battery life 11 years: 51:00 Explant 51:30 Surgical options other than Inspire 53:15 Does UPPP work? 56:00 What can we expect from surgery? 57:00 When to refer for large tonsils 59:00 Closing comments 1:01:00

In this months episode we chat with Dr. Miranda Lim of OHSU about Trauma Associated Sleep Disorder. Is it a new disorder? Does it always evolve into REM sleep Behavior Disorder? Are there any treatments? Listen to find out!

In this months episode we discuss narcolepsy with Matthew Horsnell. Matt is a narcolepsy patient and advocate, and we discuss his journey of living with narcolepsy.    SHOW NOTES Introduction of Guest: (5:00) Matt’s Best Advice (11:00) Matt’s Role in the sleep community (12:40) Matt’s symptoms onset (15:00) Matt’s additional symptoms (19:00) Matt’s onset of cataplexy (23:00) Cataplexy triggers (24:45) Delayed diagnosis: (27:00) Nightmares and sleep paralysis onset (31:30) One more question about sleep paralysis (34:15) Partial cataplexy (37:50) Diagnosis and Management: (39:00) Pitolisant (43:45) Strategic Napping (44:15) Bitter Pills (45:15) AASM revised Guidelines (47:22) Sodium Oxybate and Cataplexy (49:00) Finding a sleep physician to manage narcolepsy (55:00) Sleep apnea (60:30) MSLT (62:15) Treat Clinically (65:00) 4 pillars of management (66:00) Patient request/feedback (68:00) Academic vs private practice (71:30)     Links to articles and guidelines referenced in this episode are included  Trotti LM. Central Disorders of Hypersomnolence. Continuum (Minneap Minn). 2020 Aug;26(4):890-907. Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline

Join us this month as we discuss parasomnias with psychologist Dr. Alan Eiser.

Join us this month as we discuss OSA and cardiovascular disease with Dr. Peter Farrehi, a cardiologist at the University of Michigan. We focus on arrhythmias, but do delve into other topics as well. We hope you enjoy! Time Stamps 00:45 intro3:00 best advice6:50 pick of the month12:12 discussion begins12:30 What should we be looking for on a sleep ECG?14:00 See the patient or do the sleep study first?16:38 should every patient with afib get a sleep study?17:15 STOP BANG screening and afib19:30 arrhythmia and auto-cpap21:30 heart failure and preserved EF22:50 why does OSA predispose to atrial fibrillation26:00 anti arrhythmic drugs for afib with co-morbid sleep apnea29:00 minutes coughing can be edited if you want29:30 rate or rhythm control for afib?31:00 fatigue or sleepiness?32:20 Other sleep related arrhythmias32:36 Non sustained ventricular tachycardia33:00 Sustained ventricular tachycardia36:00 arrhythmia and management on the sleep end37:40 Long QT38:00 Chronic afib38:30 sinus pause39:30 AV block42:00 2 Lead ECG problems43:00 medicare games44:30 positional therapy47:15 virtual visits discussed vs face to face 48:30 screening afib for OSA50:33 compliance and non compliance - sleep heart health study51:00 Meta –review JAMA52:40 arrhythmia and cpap, when will my arrhythmia improve?54:30 treat sleep apnea prior to cardioversion?58:50 PVC’s1:01:00 7 pvc/minute1:02:00 PACs?1:03:00 bigeminy or trigemini?1:04:20 oxygen nadir and oxygen desaturation index1:12:30 using oxygen nadir to reach the patient1:15 wrap up

Join us as we talk with Dr. Barbara Felt about the management of ADHD in children with sleep disorders, 37:14 – Second-line medications for ADHD 38:08 – How late in the day can stimulant medications be given without risk of sleep disruption? 38:28 – How to approach the evaluation of night terrors in the patient from our case 40:22 – What is a “normal” ferritin in children? 41:15 – What is average ferritin in pre-school children? 41:40 – How do you approach a vague history provided by children regarding RLS symptoms? 43:12 – What dose of iron should be used to treat children with RLS? 44:00 – If treatment of OSA improves ADHD symptoms, is it reasonable to wean stimulant medications? 45:57 – How frequently should one re-evaluate medication doses for children with ADHD? 47:23 – Can ADHD resolve over time? Is ADHD a life-long disease? 50:32 – How commonly do children with ADHD have difficulty falling asleep? 52:15 – Discussion about behavioral insomnia of childhood, limit-setting type and combined type 54:35 – What sort of behavioral treatments are useful for children with insomnia? 56:20 – Are children with ADHD more likely to have circadian rhythm disorders? 59:00 – On the importance of sleep routines for children with ADHD 59:47 – Opportunities for research in the field of ADHD and sleep 1:02:42 – What dose of melatonin should be recommended for children? 1:05:01 – Take-home points from Dr. Felt

Show notes will be up shortly. Thank you for your patience!

Legs bothering you? Well join the The White Noise Podcast as we pick the brain of Dr. Andy Berkowski, clinical associate professor and restless leg expert at the University of Michigan. Learn all about the diagnosis and management of restless legs syndrome. There is also a guest appearance by hepcidin, the bouncer at Club Ferritin. CME credit link will be here when available Show Notes – Season 1, Episode 4 – Restless legs syndrome Time stamps 0:30 – Introduction 2:30 – Interview starts 7:40 – Picks of the month 12:50 – Case 13:50 – Initial thoughts on case 14:00 – Diagnosis of restless legs syndrome 16:50 – Diagnostic criteria for restless legs syndrome 17:40 – Difficulties in diagnosis 22:20 – Key questions to ask in taking history 24:00 – Periodic limbs vs restless legs syndrome 28:30 – Pathogenesis of restless legs syndrome 31:00 – History of Willis-Ekbom disease 35:50 – Case 36:40 – Medications for restless legs syndrome 38:30 – Dopamine agonists 43:30 – Alpha-2-delta-ligands 45:00 – Iron therapy 50:10 – PO vs IV iron supplementation 58:45 – IV iron formulations 1:00:30 – Narcotics 1:05:03 – Augmentation 1:09:00 – Non pharmacologic therapies 1:11:10 – Medications that worsen restless leg syndrome 1:16:00 – Screening for restless legs syndrome 1:18:00 – Follow-up of restless legs syndrome patients 1:18:50 – Sleep apnea and restless legs syndrome 1:20:10 – Take home points 1:22:00 – Interview end Definitions Augmentation: The process by which the symptoms of restless legs syndrome occur earlier in the day, become more severe, are less responsive to treatment, and spread to other parts of the body (e.g. arms and trunk), usually due to treatment with escalating doses of dopaminergic medications. Restless legs syndrome: A condition characterized by an urge to move one’s legs (often accompanied by unpleasant sensations in the legs) that is most prominent at rest, partially or totally relieved by movement, and classically worse in the evening. The symptoms must not be better explained by another condition such as peripheral neuropathy. Periodic limb movements of sleep: Periodic, repetitive, stereotyped limb movements that occur during sleep. American Academy of Sleep Medicine (AASM) scoring criteria require a minimum of 4 limb movements in series with 5-90 seconds between movements. Periodic limb movements of sleep are seen in the majority of patients with restless legs syndrome who undergo polysomnography. Periodic limb movement disorder: A disorder characterized by more than 15 periodic limb movements per hour of sleep in adults (greater than 5 in children) that cause a significant sleep disturbance and/or functional impairment not better explained by a different disease entity. Akathisia: An inner sense of restlessness and desire to move that is often caused by dopamine antagonist medications, is usually generalized (not limited to the legs), and is unlikely to be totally relieved by movement. Clinical Pearls Restless legs is a clinical diagnosis The hallmark of the disease is a SENSATION  of the need to move. There must be a circadian component to make a diagnosis. Augmentation will almost inevitably occur with dopamine agonists. Target ferritin >75 and transferrin saturation greater than 20% for iron repletion. Obtain fasting ferritin levels. Some times less iron is better than too much;

This episode was written and produced by John Barkham, MD, Mohan Dutt, MD, and Alok Sachdeva MD. Join The White Noise Podcast in part II of their discussion on nightmare disorder. In this episode we speak with Dr. Todd Favorite, an expert in the treatment of PTSD and nightmare disorders. Show Notes Season 1-Episode 3- Nightmare Disorder Part 2 Time Stamps 0:00 – Introduction 0:30 – Get to know Dr. Favorite 2:45 – Pick of the Month Paths of Glory by Jeffery Archer 5:00 – Clinical Case 6:45 – Initial Evaluation 8:00 – Nightmares in the setting of post-traumatic stress disorder 16:00 – Dream rescripting 22:00 – How to evaluate success 28:00 – Choosing the right patient 30:00 – How to address nightmares with patients 38:00 – Scoring systems 39:45 – More information on dream rescripting 42:00 – Co-therapy with medication 45:00 – How to be successful 47:00 – Medication vs nightmare reduction therapy Dr. Favorites Recommended Reading List Davis, J.L., Treating Post-Trauma Nightmares : A Cognitive Behavioral Approach. Springer Publishing Co. NY Favorite, T.K., Conroy, D. (2018). Psychosocial Treatments for Trauma-Based Nightmares. Psychiatric Times, Sept 2018  Swanson, L., Favorite, T.K, Arnedt, T., Horin, E. (2009).A Combined Treatment for Nightmares and Insomnia in Combat Veterans: A Pilot Study. Journal of Traumatic Stress, 22(6): 639-642. Krakow,.B. , et.al. (2001). Imagery Rehearsal Therapy for Chronic Nightmares in Sexual Assault Survivors With Posttraumatic Stress Disorder A Randomized Controlled Trial. JAMA, August 1, 2001—Vol 286, No. 5 Mysliwiec, V., O’Reilly, B., Polchinski, J., et.al. (2014). Trauma Associated Sleep Disorder: A Proposed Parasomnia Encompassing Disruptive Nocturnal Behaviors, Nightmares, and REM without Atonia in Trauma Survivors.Journal of Clinical Sleep Medicine, Vol. 10, No. 10 Disclosures The authors of The White Noise Podcast do not have any financial disclosures.

Episode written and produced by John Barkham, MD, Mohan Dutt, MD, and Alok Sachdeva MD. The White Noise Podcast discusses the medical management of nightmare disorders with our very own Dr. John Barkham, who is a clinical lecturer at the Ann Arbor VA. This is part one of our two part series on nightmare disorders. Show Notes Season 1-Episode 2- Nightmare Disorder Part 1  Time Stamps 0:00 – Introduction 4:51 – Guest Introduction 8:10 – Picks of the month Maps of Meaning by Jordan Peterson 12 Rules for Life by Jordan Peterson The Big Fella by Jane Leavy Star Trek: Discovery 11:29 – Clinical case begins 11:40 – Evaluation of nightmares The effect of continuous positive air pressure (CPAP) on nightmares in patients with posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA). 22:00 – Nightmares in the veteran population 25:30 – Prazosin use for nightmare disorder Clinical case series: the use of Prazosin for combat-related recurrent nightmares among Operation Iraqi Freedom combat veterans. 28:00 – Diagnostic criteria for nightmare disorder Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper 32:05 – Disturbing dreams and nightmare severity index (DDNSI) Nightmare complaints in treatment-seeking patients in clinical sleep medicine settings: diagnostic and treatment implications. 34:00 – Resumption of case 37:45 – Prazosin dosing 41:50 – Problems with the DDNSI 47:18 – Pharmacologic alternatives to prazosin 51:00 – Alternatives to pharmacotherapy Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. Additional Information From: Callen et al, Nightmare Disorders in Adults From: Callen et al, Nightmare Disorders in Adults Disclosures The authors of The White Noise Podcast have no financial disclosures